Still awake? How to get to sleep when you can’t

Oct 1, 2016

Rate this article and enter to winTired? Lying awake at night? If you have insomnia, you may take a half-hour or longer to fall asleep and frequently get less than six hours, according to the Mayo Clinic. And you know how badly that messes with your life. Sleep deprivation leads to fatigue, mood swings, increased appetite, diminished functioning, memory impairment and lower grades, and contributes to physical and emotional health problems, research shows.

Even if you’re familiar with insomnia, you may not know its first-line treatment (as recommended by the American Society of Physicians): cognitive behavioral therapy (CBT), a type of short-term counseling, in a format that specifically addresses insomnia (CBT-I). “The data is exceptional in that 75–80 percent of insomnia patients improve with this treatment,” says Dr. Kelly Glazer Baron, a clinical psychologist and founder of the Behavioral Sleep Medicine training program at Northwestern University Feinberg School of Medicine, Illinois.

College students who received CBT-I showed improved sleep quality and reduced fatigue compared to those who didn’t, according to a small study in Behavior Therapy (2014). “This is a simple approach that works,” says Dr. Gregg Jacobs, insomnia specialist at UMass Memorial Medical Center, Massachusetts. “People say they’ve slept the best they ever have in their life.”

Student’s story

“I’m more OK with myself than I ever have been.”

Donna L., a fourth-year undergraduate at the University of Wyoming who returned to school in her 50s, has used CBT-I to help her with insomnia, depression, anxiety, stress, and a difficult childhood.

“With CBT, you retrain your thought processes. For example, two hours before bed, you start thinking about how you’re going to sleep, how you’re planning to wash away your stress, and removing obsessive thinking.

“I had a recurring nightmare for decades. My therapist taught me that there’s nothing to be afraid of, and that trauma in your nightmares is in the past. I haven’t had the dream in years.

“CBT is so important in retraining your brain. My confidence level has changed drastically; I’m just more OK with myself than I ever have been.”

For methods, see Short-term therapy: How CBT-I works

CBT-I is so effective that it’s the first-line treatment for adults with chronic insomnia. That’s the recommendation of the American College of Physicians (ACP), following more than a decade of research.

What’s the problem with sleeping pills? Sleeping medications can be useful for some people in some situations, but they don’t provide a long-term fix, and they come with side effects and risk, including dependency and addiction.

In studies, medications such as Ambien and Restoril appear to double the users’ risk of car accidents (American Journal of Public Health, 2015). In a 2012 study, the use of prescription sleep medication was associated with markedly earlier death, according to BMJ Open (this does not mean the medications actually caused those deaths). In addition, sleeping pills don’t extend our sleep nearly as long as we might think—most add only a few minutes a night, according to a 2007 analysis in the Journal of General Internal Medicine.

“College students are one of the groups that has the highest instances of sleep problems. I think that things like CBT-I should be part of the college curriculum. If they [students] don’t know how to sleep better and not to rely on sleep medications or narcotics, then they’re setting themselves up for a lifetime reliance on prescription drugs.”

—Dr. Gregg Jacobs, insomnia specialist, UMass Memorial Medical Center, the clinical partner of the University of Massachusetts Medical School

+ Sleepio A year of support from sleep scientists who communicate online, offering advice and answering questions.Cost $300

CBT-I Coach Free app from the US Department of Veteran Affairs; this complements sleep therapy but does not substitute for it.+ iOS + Android

CBT is a short-term therapeutic approach that can help people with a variety of emotional and behavioral issues, including symptoms of post-traumatic stress disorder, depression, and anxiety.

CBT involves a set number of sessions aimed at addressing an identified issue. To treat insomnia, you need CBT-I specifically.

CBT-I is available in traditional counseling settings and online.

Your CBT-I provider or program will help you identify the unhelpful thought patterns and behaviors that are messing with your sleep. They will help you reframe those thoughts and substitute more effective behaviors. “[CBT-I] changes the way you think about your sleep,” says Dr. Baron. (For example, “I always have trouble falling asleep” can be reframed as “I’m going to relax and let myself drift into sleep, and be refreshed tomorrow.”)

During CBT-I, you might keep a diary of your sleep patterns. This can help reveal habits or thoughts that could be contributing to your insomnia. Your clinicians can then offer customized “assignments” intended to reshape your daily approach to nocturnal activities. These may include limiting activities in your bed to sleep (no more working or texting in bed), getting up and leaving your bedroom when you can’t sleep, and cutting out naps.

“Ironically, sleep is one of those things where the more you think about trying to sleep, the worse [your inability to do it] becomes. You can’t ‘try’ to sleep. So there are people who lie in bed for hours trying to sleep, and it’s a self-fulfilling prophecy.”

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